Electronic DSHS Forms

You may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader.

We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management.

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Number(desc) Form Name File Format
10-622 Certified Community Residential Services(CCRSS) Group Training Home Food Service Review (Residential Care Services) and Supports
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-625 State Task Checklist (Aging and Long-Term Support Administration)
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
10-629 Pet Record Review (Aging and Long-Term Support Administration)
10-630 Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration)
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
10-636 Meaningful Day Monthly Calendar
10-637 Meaningful Activity Plan (MAP) Discovery
10-638 AFH Meaningful Day - Monthly Activities and Challenging Behavior Log
10-639 Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
10-645 Residential Certification Evaluation Client Interview (Developmental Disabilities Administration)
10-646 Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration)
10-647 Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration)